Lumps and Bumps in the Bladder – A Novice’s Quick Guide to Bladder Cancer

By Dr. Alexander W. Pastuszak, a resident physician at Baylor College of Medicine

The treatment of bladder cancer can be very confusing to patients, and appropriate decision-making can be challenging for their physicians as well. This is because while we know a lot about bladder cancer, we don’t know enough to provide a yes or no answer to every question. The goal of this post, therefore, is to provide a very brief overview of the main types of bladder cancer and generally how these are treated. Depending on your urologist, these treatments can vary quite a bit, but the premise should remain the same – to get rid of or minimize the growth of the cancer.

Background

Bladder cancer, like any cancer, arises as a result of DNA mutations in the affected cells. This trips a switch that causes these cells to grow without consideration for the cells around them and essentially out of control. Bladder cancer arises from the lining of the bladder, also called the urothelium. Unlike other cancers, urothelial cancers are considered “field defects,” meaning that while visible tumors may arise in one part of the bladder lining, other parts of the lining already have the genetic changes that may cause tumors to form there as well. This is likely because those cells have been exposed to whatever mutagenic chemical cause the initial tumors to form since the urothelium is bathed in urine. As a result, once someone is diagnosed with bladder cancer, he or she requires life-long monitoring to stay on top of the disease. This is also why bladder cancer tends to affect older folks – it takes time for these genetic changes to occur. Incidentally, the most significant risk factor for bladder cancer is a history of smoking. In addition, exposure to chemicals, most notably aromatic amines found in aniline dyes, as well as chronic infection or irritation of the bladder and exposure of the bladder to radiation also increases your risk.

Types of Bladder Cancer and Treatment

So let’s say you’ve had blood in your urine and you see your urologist and he or she looks inside your bladder and sees a lump that looks like a tumor. What then? First, your urologist will recommend a biopsy of the tumor so that 1) a diagnosis of bladder cancer can be made and 2) all the layers of the tumor and bladder wall beneath it can be examined under a microscope. The depth of penetration of the tumor, as well as the appearance of the cells (termed “grade”) will determine future treatment. For example, if the tumor is “low grade” and either does not penetrate the bladder wall or only goes through the superficial layers, called the lamina propria and muscularis mucosa, then there’s a very low likelihood that the tumor has spread beyond the bladder and removal of the tumor itself is sufficient initial treatment. This type of tumor, regardless of grade, is called non-muscle-invasive bladder cancer and represents about 75% of bladder tumors. If the tumor is “high-grade” and non-muscle-invasive, the chances of tumor spread are still higher than those of “low-grade” tumors, as are the chances that the tumor is actually invading more deeply than the first biopsy showed. As a result, a second biopsy of the tumor site is usually taken within 4-6 weeks.

For patients with non-muscle-invasive bladder tumors, most urologists, depending on the number of tumors found initially, as well as their size, may recommend further initial treatment in the form of chemotherapy into the bladder, which has been shown to significantly decrease the chance of new tumor growth.

What about if the tumor has penetrated into the deeper layers of the bladder wall, which include the bladder muscle, or muscularis propria? In this case, the risk of tumor spread outside of the bladder increases and treatment is more aggressive. This type of bladder cancer is termed muscle invasive bladder cancer. At this point, some urologists recommend a CT scan to look for signs that the tumor has spread, such as enlarged lymph nodes in the pelvis or nodules in the lungs. If there is suspicion that the cancer has spread outside the bladder, your urologist may recommend chemotherapy initially, followed by surgery. Some urologists will perform surgery first, and then give chemotherapy. Studies have shown that both ways of treating this form of cancer are effective. However, once the cancer has spread outside of the bladder, the chances of cure are very low.

If there are no visible signs of cancer spread on imaging studies, but the tumor is invading into the bladder muscle, the next step in treatment is usually surgery to remove your bladder and divert your urine. In addition, the lymph nodes in the pelvis, which is the first area that bladder cancer typically spreads to, are sampled during the surgery as well to determine if cancer is present in these nodes, which would require subsequent chemotherapy after surgery. There are several options for urinary diversion, which include building a new bladder from intestine or diverting the urine to flow out of a conduit built into your abdominal wall, and the type that a patient ends up receiving is based on several factors and personal preference, all of which can be discussed with your urologist prior to surgery.

Regardless of what form of bladder cancer you have – invasive or non-invasive – you need to be prepared to regularly see your urologist anywhere from 1-4 times per year after this diagnosis and initial treatment in order to keep you disease-free. I’ve only scratched the surface of bladder cancer treatment in this post, so if you have questions, please ask!